Michael Truss | PubMed Health

PubMed2005

Laparoscopic radical prostatectomy--the experience of the German Laparoscopic Working Group.

PURPOSE: To present the current status of laparoscopic radical prostatectomy (LRP) in Germany, Austria and Switzerland with respect to transferability, learning curve, and outcome. MATERIAL AND METHODS: The data of 5824 patients who underwent LRP in 18 centers by 50 urologists from March 1999 to August 2004 were analyzed retrospectively. Three centers performed more than 500, and six more than 250 cases. A transperitoneal descending technique with was used in 2701, a transperitoneal ascending in 1234, an extraperitoneal descending in 1814, and an extraperitoneal ascending modification in 75 cases. Specimen showed pT2 in 3535, pT3a in 1555, pT3b in 623, and pT4 in 111 cases. RESULTS: Mean operating time averaged 211 (131-292) minutes, with shorter duration of the extraperitoneal descending technique. Conversion to open surgery averaged 2.4 (0-14.1) %. Re-intervention rate amounted to 2.7 (0.3-7.7) %. Complication rate averaged 8.9 (1.8-10.8) % including bleeding (0.3-2.5%) and rectal lesion (1.5-2.5%). The rate of positive margins was 10.6 (3.2-18) % for pT2- and 32.7 (20-38.5) % for pT3a-tumors Continence after 12 months was 84.9 (72-94) %. Data about potency (7 centers) revealed 52.5 (35-67) % full erections following bilateral nerve preservation. 5 year-PSA recurrence rate (3 centers) was 8.6 (4-15.3) % for pT2-tumors and 17.5 (15-20.6) % for pT3a-stages. CONCLUSIONS: The results confirm the efficacy of the training program with safe transfer of LRP (i.e. low complication rate), however including all known problems of a retrospective study.

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PubMed2005

Modular surgical training for endoscopic extraperitoneal radical prostatectomy.

OBJECTIVE: To develop a modular training scheme which enabled the use of individual steps of laparoscopic radical prostatectomy (RP) for teaching and training surgeons with varied experience, including residents with no experience in open RP, as in extending laparoscopic surgery to more complex operations like RP, the proper training of urologists is crucial. SUBJECTS AND METHODS: The technique of endoscopic extraperitoneal RP (EERP) was divided into 12 individual steps of differing complexity. The levels of difficulty were called "modules" and graded according to their requisite skills from module 1 (lowest level of difficulty) to module 5 (highest level). Based on this modular system we established a training programme whereby the trainee learns the procedure in a mentor-initiated schedule. During each training operation the trainee only performs the modules (steps) of the operation, which correspond with his or her actual skill level. The mentor performs all the other steps, with the trainee assisting. Four trainees with different surgical experience participated in the study. RESULTS: After a phase of assisting and camera holding during EERP, the trainees entered the modular training programme and required 32-43 procedures until they were considered to be competent. An analysis of the first 25-50 procedures done independently by the trainee showed mean operative times of 176-193 min and a transfusion rate of 1.3%. Complications during and after EERP requiring re-intervention were one each of recto-urethral fistula, haemorrhage, symptomatic lymphocele and anastomotic leak. The positive margin rate for pT2 disease was 12.2% and for pT3 tumours 37%. CONCLUSION: The modular concept for teaching EERP is an attractive concept, which overcomes many of the problems involved in complex laparoscopic procedures. Based on a highly standardized technique, this concept offers a short learning curve; it enables training on different sites in cooperation with a high-volume centre, and it makes it possible to start with this complex procedure as a beginner or with no experience in open RP.

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